Enterprise

Appointment Request

If this is a medical emergency, please call 911 immediately.

Please complete the form below to request an appointment for your child.

We will attempt to contact you within 24 hours or sooner when your request is submitted Monday through Friday during our business hours of 8 a.m. to 4:30 p.m. For requests submitted Friday evening through Sunday or holidays, we will contact you the next business day.

To talk to a scheduler, call our Physician Referral Line at 412-692-PEDS (7337) from 7 a.m. to 7 p.m. Monday through Friday.

* Indicates a required field.

Patient Information

First Name
*

Middle Initial

Last Name
*

Address Line 1
*

Address Line 2

City
*

State
*

Zip Code
*

Patient's Date of Birth
*

Gender
*

Male
Female

Health Insurance
*

Contact Information

Parent/Guardian Name

First Name

M.I.

Last Name

E-mail
*

Phone Number (where you can be reached from 8a.m. to 4:30p.m.) Format: 555-555-5555
*

Preferred Method of Contact
*

Telephone

Best Time to Call

Appointment Information

Specialty
*

Preference

Reason for Appointment
(Indicate if you are a new or returning patient and/or enter your desired physician)

We will attempt to contact you within 24 hours or sooner for requests submitted during the weekday. For requests submitted Friday evening through Sunday or holidays we will contact you the next business day.